Palliative care in the elderly

[redtshirt]

At the moment im working in an acute medical elderly unit. There are a lot of patients who on admission are discussed with family and team and decided how far interventions should go with the patients, eg feeding tubes, recussitation, ventilation etc. I think this is ideal as you never know what hour of the day or night something might happen. I have one patient who is now listed as 'palliative' patient is bed bound with no infection(just cleared), has subcut fluids some days with potassium added depending on bloods. She doesnt take anything orally no food no fluids and is suported solely by those sub cut fluids. The family have decided no feeding tubes but the patient is much better than she was at the time of the decision. I just feel that its wrong that this patient is getting no nutrition via an NG, PEG, or RIG line. A patient without dementia may be able to verbilise hunger. Is she starving to death or am i looking at this in the wrong way? Either way i think the team and famly need to meet again to discuss patietns progress.

[heron, ASN, RN]

It's an excellent question and one that is asked often ... as it should be. There is no pat answer that covers all situations.

I'm assuming here that you're asking about patients who have permanently lost the ability to swallow due to advanced dementia or overwhelming neuro issues such as massive stroke.

First of all, you have to accept that there's no way you can know what a non-verbal dementia patient is feeling. You can only go by non-verbal cues ... do you see any indication of discomfort and under what circumstances? Grimacing, restlessness ... does the patient make any attempt to swallow when something is placed in the mouth?

Being hungry is a comfort issue, for sure ... you just can't know for sure.

As for the patient dying of starvation ... actually, the patient is dying of dementia or stroke ... starvation may be the mechanism, but it isn't the cause. If the cause of the starvation is irreversible and there's no chance the patient will recover the ability to eat normally, then you have to start considering the risk-benefit ratio of artificial feedings, which the team on your unit seems to be doing very well.

It is true that the life of the body of the patient will be prolonged with artificial feeding, just as it already is with artificial fluids. The question then becomes "Why?" Is the quality of life possible for someone with end-stage dementia or irreversible brain damage worth the risks involved in artificial feedings, if the patient can tolerate them to begin with? Just what is your goal of treatment? To prolong life or a peaceful death?

I could certainly tell you my own opinion, but I don't want to tell you what to think ... these questions might help you think things through.

[redtshirt]

Well a peaceful death is more what we are aiming for. It does make me feel better to know the patient is dying from a disease process instead of starvation though. She wont attempt a swallow at all. She wont let us do oral care either unless you manage to catch her off gaurd shell purse her lips together so i suppose that would mean she doesnt want food either. Think thats my answer! Thanks!

[heron, ASN, RN]

It was entirely my pleasure.

One of the first signs that someone is beginning the process of active dying is the loss of desire or ability to eat. As nurses and as caring people, we want to meet our patients' needs and the need for food and water is the most basic. We have not yet integrated the dying process into our ideas about life and the hierarchy of needs, so it can be hard to wrap your head around the idea that, at the end of life, the person actually needs to stop eating.

Go gently with yourself and with the families of your patients. This is a hard one.

[heron, ASN, RN]

She wont let us do oral care either unless you manage to catch her off gaurd shell purse her lips together so i suppose that would mean she doesnt want food either. Think thats my answer! Thanks!

You could also be seeing a "snout reflex" ... a very primitive reflex that occurs when the frontal lobes are pretty much destroyed.

[SuesquatchRN, BSN, RN]

You could also be seeing a "snout reflex" ... a very primitive reflex that occurs when the frontal lobes are pretty much destroyed.

I have to look that up. Thanks.

[heron, ASN, RN]

I just found out about it, myself. Then I realized that I'd been seeing it a lot over the years ... just didn't know what it was or what it meant.

[achot chavi]

Whatever you decide I can imagine the staff having emotional difficulties with this patients care, I know some of my staff would avoid the room as it would be too upsetting. I would schedule a short staff meeting with the SW to allow staff to vent their feelings so that they can overcome personal feelings in order to provide the prescribed care. The family must need a huge amount of understanding and patience.

[CapeCodMermaid, RN]

what are subcut fluids and what is a RIG line?

We don't do fluids unless it's PO or IV.

[heron, ASN, RN]

what are subcut fluids and what is a RIG line?

We don't do fluids unless it's PO or IV.

The fancy term for subcu fluids is hypodermoclysis ... clysis for short. A short small gauge needle is placed subcutaneously and secured just like an iv. There are needle sets made especially for this or you can use a butterfly. You can give fluids as a continuous drip, albeit more slowly than is possible with an iv, or cap it and use it like a hep lock, only you don't use heparin to flush, just normal saline. You can give any meds you can give subcu via a clysis. In hospice we frequently use them for opioid drips. Much less uncomfortable and persnickety than an iv.

In one hospital where I worked, we had a chronic floor and used an overnight clysis to keep the little old ladies hydrated.

Never heard of a RIG line ... can't even begin to guess!

[CapeCodMermaid, RN]

zowie...we have used clysis in years and years around here.

[Paulred]

The ethics dilemma...